Acta Pædiatrica ISSN 0803-5253
REGULAR ARTICLE
Kangaroo mother care in the neonatal intensive care unit: staff attitudes and beliefs and opportunities for parents H Strand1, YT Blomqvist2, M Gradin3, KH Nyqvist ([email protected].)4 1.School Health Nurse, Katedralskolan, Uppsala, Sweden 2.Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden € 3.Neonatal Intensive Care Unit, University Hospital, Orebro, Sweden 4.Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
Keywords Healthcare professionals, Kangaroo Mother Care, Neonatal intensive care units, Nursing practice, Preterm infants Correspondence K H Nyqvist, Associate Professor, Department of Women’s and Children’s Health, University Hospital, S-751 85 Uppsala, Sweden. Tel: +46186119104 | Fax: +46186115583 | Email: [email protected] Received 18 June 2013; revised 9 October 2013; accepted 26 November 2013. DOI:10.1111/apa.12527
ABSTRACT Aim: To compare attitudes towards Kangaroo mother care (KMC) among staff in two hightech neonatal intensive care units, which provided parents with different opportunities to get involved in their infants’ care. Method: Questionnaires were completed by healthcare staff in Unit A, which provided parents with unrestricted access so that they could provide continuous KMC, and Unit B, where parents could only practice KMC intermittently. Results: Unit A staff were more positive about the benefits and use of KMC, including its use in unstable infants, and rated their knowledge and practical skills more highly than staff in the other unit. Unit B staff also appreciated the method, but expressed more hesitation in using it with unstable infants. In particular, they stressed the need to adapt the physical environment of the NICU to enable parents to stay with their infants and practice the method. Conclusion: Staff working in the NICU that gave parents unrestricted access were more positive about KMC than staff in the NICU that offered limited opportunities for parents to stay with their children. This finding suggests that it is important to eliminate unjustifiable obstacles to the presence of parents in the NICU, so that they can provide KMC.
INTRODUCTION Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s. Low birth weight and preterm infants were cared for by their mothers using continuous skin-to-skin contact 24 hours a day. They were exclusively breastfed or fed with breast milk, whenever possible, and discharged home early with a scheduled follow-up programme (1). This KMC model is now practised more frequently in lowincome settings, whereas in high-tech neonatal intensive care units (NICUs) intermittent KMC sessions of 1 or 2 h per day are more common. For the sake of simplicity, the term KMC will be used here to cover both continuous and intermittent care. Compared to conventional neonatal intensive care, with infants spending most of their time in an incubator, KMC yields several benefits (1,2). These include increased physiological stability, decreased pain response, stress reduction, better sleep state organisation and more normal neurobehavioural and psychomotor development. These effects are also noted in very and extremely preterm infants and term infants requiring intensive care. The method may contribute to fewer severe infections and reduce the infant’s hospital stay (3). Furthermore, KMC facilitates breastfeeding (1), especially for the most vulnerable infants (4). Other benefits include lower maternal depression scores and a
more developmentally oriented caregiving family environment during the first year, as fathers’ involvement in KMC also has a positive impact (2). Swedish mothers who practiced continuous KMC said that they liked this close contact with their infant, although some of them were dissatisfied with the support offered by the nursing staff (5). Swedish fathers who provided KMC from the infant’s birth felt that it helped them to establish their paternal role more quickly after birth, as they could provide the infant’s basic care and become more independent of the nurses (6). When an infant is admitted to a NICU, the new parents (rather than just the mother) need to bond with their new
Key notes
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 373–378
This study compared the intermittent model of Kangaroo Mother Care (KMC), which has been the norm in high-tech NICUs until recently, with continuous KMC. Staff who worked in a NICU that enabled continuous KMC were more positive and confident about the process, including its use in unstable infants. To successfully implement KMC, NICUs need to provide the facilities that parents need to stay with their children round-the-clock.
373
Kangaroo mother care in the NICU
Strand et al.
baby and interact with staff (7). As parent–infant bonding should be regarded one of the primary goals of neonatal care, KMC should be promoted as a means of humanising the care an infant receives, in addition to other benefits (8). The World Health Organisation has recommended KMC as a universal model of care in all types of settings, because the evidence shows that it benefits infants and families (9). As a result, starting continuous KMC immediately after birth, or as soon as possible after stabilisation, has also been recommended for infants in high-tech NICUs (2). However, as both positive and negative staff attitudes have been found to affect parents’ application of KMC, the method is an example of a clinical practice based on attitudes rather than scientific evidence (10). Although KMC is also safe for infants receiving mechanical ventilation (11), staff concerns about the early introduction of KMC and infant safety during the process are common (12). Staff have suggested that implementing the method could lead to unwelcome lower staffing levels and increased workloads (12). Furthermore, the signals conveyed by the physical and social environment in conventional high-tech NICUs do not encourage parents to stay with their infant (2). It can be assumed that providing family rooms and recliners or parent beds in NICUs may increase the parents’ presence and performance of KMC. This may, in turn, influence how staff perceive the method. The intermittent model of KMC has become common in affluent Western countries Therefore, the introduction of continuous KMC as the norm in a Swedish high-tech NICU (5,6,13) provided the impetus for this study, as research was lacking about staff attitudes to KMC in this type of setting, together with beliefs about the different modes of application.
AIM The aim of the study was to describe and compare staff attitudes towards KMC at NICUs that provided different opportunities for parents to stay with their infant and practice KMC. Two research questions were formulated. The first explored differences in staff attitudes to KMC between the NICUs, in relation to the benefits and drawbacks of KMC, infant criteria for the use of KMC, opinions about the parents’ performance of KMC and staff issues linked to KMC. The second focussed on the spontaneous comments about KMC made by the respondents in the two units. Our hypothesis was that staff who were positive about KMC would also be more positive in the unit that provided an environment that enabled the parents to be with their infants at all times.
MATERIAL AND METHODS Design A cross-sectional survey was carried out among all the clinical staff in two NICUs using a questionnaire (Likert scale) with additional space for free comments.
374
Setting and sample The study was performed in the NICUs at two Swedish University hospitals. It was carried out in Unit A 4 years after the NICU had been redesigned to enable at least one parent to stay with their child 24-hours-a-day throughout their whole hospital stay and provide 24/7 KMC if they wished. Guidelines for the introduction of continuous KMC, according to gestational age at birth, were introduced at the unit at the same time. In Sweden, the national insurance system makes it possible for parents to stay with their hospitalised child round-the-clock as both parents can share ‘temporary parental benefit’ until the infant is formally discharged from hospital. Unit A had 23 beds. These included 14 intensive care incubators or cribs in open bay nurseries, with an adult bed next to each of them, enabling one parent to stay 24 hours a day. Two adult beds were provided for parents with twins. The unit also included nine family rooms, where parents and siblings could stay day and night with the infant, from birth, or after the transition from the intensive-care nursery, until they were discharged. Relatives and other close friends were welcome to visit and could be designated by the parents as substitute KMC providers. The NICU provided a family kitchen and lounge and sibling play areas. Postnatal nursing care was provided by midwives in the postnatal ward, making it possible for mothers with normal deliveries to stay with their infants day and night from birth. Unit B was a conventional 17-bed NICU with five intensive-care beds and 12 intermediate-care beds. Parents had access to a recliner in their infant’s care space in both sections. This NICU had three family rooms, where parents could stay with their stable infant round-the-clock, at least for a couple of days before discharge. A family kitchen and lounge was also available. The parents were supported as much as possible if they wanted to provide KMC. In contrast with Unit A, the KMC protocol at Unit B did not include any guidelines for the introduction of continuous KMC. Approval to conduct this study was obtained from the medical directors of both study units. Data collection method The questionnaire design was based on a similar study (12) and the authors’ clinical experience. One nurse, physician and assistant nurse from each NICU reviewed the questionnaire to ensure its content and validity, and minor changes were made based on their suggestions. The questionnaire consisted of 22 statements about the benefits and drawbacks of KMC, infant criteria for the use of KMC, opinions about parents’ performance of KMC and staff issues linked to KMC. Participants were asked to indicate their agreement with each statement, using a Likert scale where 0 meant ‘disagree’ and 10 meant ‘strongly agree’. The questionnaire also included questions about the participants’ profession and experience of neonatal care, as well as questions requiring a ‘yes’ and ‘no’ answer on theoretical and practical education in KMC, written sources of knowledge about KMC and clarity of the NICU’s KMC guidelines.
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 373–378
Kangaroo mother care in the NICU
Strand et al.
Sample and data collection procedure All registered nurses (RN), physicians and assistant nurses working in the NICUs at the time of the data collection were invited to participate. A list of participants was compiled and questionnaires were numbered according to the list, making it possible to remind staff members who did not respond within the prescribed time. The list of participants was kept confidential and destroyed after the data collection had been completed. The questionnaires were distributed using individual mailboxes and lockers at the two NICUs. Participants who did not submit their questionnaires in 10 days were supplied with a new questionnaire and asked to submit it no later than 3 weeks later. Acceptable response rates were achieved after one reminder. Data analysis Data from the questionnaires were entered into the Statistical package for the social sciences (SPSS) version 20.0 (IBM corp., Armonk, NY, USA). The Mann–Whitney U-test was used to compare the independent samples. A p < 0.05 was considered significant. Responses to the open questions were categorised according to the four content areas in the questionnaire.
RESULTS Response rate and respondents’ profile We distributed a total of 165 questionnaires: 74% of the Unit A questionnaires were returned (85/115), together with 74% of the Unit B questionnaires (41/50). About half of the 85 respondents in Unit A were assistant nurses (42), followed by RNs (33) and 10 physicians. Most of the staff (69%) had worked in neonatal intensive care for 10 years or more. In Unit B, 25 respondents were RNs, 10 were assistant nurses and six were physicians. Three of four respondents (76%) had 10 years or more of experience of neonatal care. The majority of the participants in Unit A said that they had received theoretical education about KMC, compared to about half of the staff in Unit B. About three of four respondents in Unit A had participated in practical training, compared to about half of the respondents in Unit B. Nearly all of the respondents in Unit A agreed that the KMC guidelines were clear, whereas the proportion in Unit B was somewhat lower. The use of literature as a source of knowledge was less common in both units. About one of three participants in both NICUs had read about KMC on the internet. Staff responses to questionnaire statements Benefits and drawbacks of KMC Staff in both NICUs agreed about the positive effects of KMC on parent–infant bonding/attachment, parents’ selfconfidence and infants’ physiological status and general wellbeing (Table 1). However, staff in Unit A indicated lower agreement scores than staff in Unit B on overstating the benefits of KMC (a mean score of 1.3 versus 2.4) and that KMC increases the risk of hazards (1.7 versus 2.4).
Table 1 Benefits and drawbacks of KMC Statements Benefits KMC promotes parent–infant bonding/attachment KMC has positive effects on the infant’s physiological status KMC has positive effects on the infant’s general wellbeing KMC has positive effects on parents’ self-confidence Drawbacks Potential benefits of KMC have been overstated KMC leads to increased hazards for the infant
Unit A M (range)
Unit B M (range)
p
9.6 (5–10)
95 (7–10)
ns
9.3 (6–10)
9.1 (5–10)
ns
9.3 (5–10)
9.2 (6–10)
ns
9.3 (2–10)
9.0 (5–10)
ns
1.3 (0–9)
2.4 (0–8)
0.001
1.7 (0–9)
2.4 (0–6)
0.002
M = Mean; ns = Nonsignificant.
Several comments by respondents from Unit A addressed the risk of extubation and dislocation of umbilical catheters during infant transfer between the incubator and a parent, together with the risks for infants that may be too instable to tolerate KMC, especially extremely preterm infants. Correct infant positioning to ensure that their airways remained free and appropriate clothing during KMC were felt to be essential for infant safety. Infant criteria for use of KMC There were significant differences between the units regarding safety concerns (Table 2). Staff in Unit A were more positive about using KMC on infants receiving ventilator or continuous positive airways pressure treatment. Staff at both units expressed similar hesitation about using KMC in infants with an umbilical catheter and during the first week of life in infants born at a gestational age of below 28 weeks. Staff in both units were equally positive about introducing KMC in stable infants born at gestational ages of ≥28 weeks, One respondent in Unit B stated that the transfer of an intubated infant from the incubator to a parent required further deliberation before it became common practice, because of safety issues. Opinions on the parents’ performance of KMC Staff members in Unit A were more positive about offering all parents the opportunity to use KMC day and night, both in the family rooms and open bay nurseries. They were also convinced that parents would want to sleep with their infant skin-to-skin during the night (Table 3). Staff in both NICUs expressed mixed feelings about whether parents might feel forced to practice KMC by staff, with mean agreement scores of 4.9 in Unit A and 5.0 in Unit B. In Unit A, several comments addressed parents’ needs, especially when there were siblings, and highlighted the importance of easing parents’ stress by showing them
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 373–378
375
Kangaroo mother care in the NICU
Strand et al.
Table 2 Infant criteria for use of KMC Statements
Unit A M (range)
Unit B M (range)
p
5.0 (0–10) 3.0 (0–10) 0.9 (0–3)
0.000 ns 0.01
2.4 (0–10)
ns
9.2 (4–10)
ns
Unit A M (range)
Unit B M (range)
p
9.5 (5–10)
9.0 (4–10)
0.016
4.9 (0–10)
5.0 (1–10)
ns
8.4 (1–10)
6.4 (0–10)
0.000
8.7 (1–10)
6.1 (0–10)
0.000
6.3 (1–10)
4.2 (0–8)
0.000
KMC should be limited or avoided when the infant Is intubated 1.4 (0–8) Has an umbilical catheter 2.7 (0–8) Continuous positive airway pressure 0.5 (0–8) treatment is an obstacle to KMC KMC can be introduced during the 2.7 (0–10) first week of life when the infant born is at a postmenstrual age of
REGULAR ARTICLE
Kangaroo mother care in the neonatal intensive care unit: staff attitudes and beliefs and opportunities for parents H Strand1, YT Blomqvist2, M Gradin3, KH Nyqvist ([email protected].)4 1.School Health Nurse, Katedralskolan, Uppsala, Sweden 2.Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden € 3.Neonatal Intensive Care Unit, University Hospital, Orebro, Sweden 4.Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
Keywords Healthcare professionals, Kangaroo Mother Care, Neonatal intensive care units, Nursing practice, Preterm infants Correspondence K H Nyqvist, Associate Professor, Department of Women’s and Children’s Health, University Hospital, S-751 85 Uppsala, Sweden. Tel: +46186119104 | Fax: +46186115583 | Email: [email protected] Received 18 June 2013; revised 9 October 2013; accepted 26 November 2013. DOI:10.1111/apa.12527
ABSTRACT Aim: To compare attitudes towards Kangaroo mother care (KMC) among staff in two hightech neonatal intensive care units, which provided parents with different opportunities to get involved in their infants’ care. Method: Questionnaires were completed by healthcare staff in Unit A, which provided parents with unrestricted access so that they could provide continuous KMC, and Unit B, where parents could only practice KMC intermittently. Results: Unit A staff were more positive about the benefits and use of KMC, including its use in unstable infants, and rated their knowledge and practical skills more highly than staff in the other unit. Unit B staff also appreciated the method, but expressed more hesitation in using it with unstable infants. In particular, they stressed the need to adapt the physical environment of the NICU to enable parents to stay with their infants and practice the method. Conclusion: Staff working in the NICU that gave parents unrestricted access were more positive about KMC than staff in the NICU that offered limited opportunities for parents to stay with their children. This finding suggests that it is important to eliminate unjustifiable obstacles to the presence of parents in the NICU, so that they can provide KMC.
INTRODUCTION Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s. Low birth weight and preterm infants were cared for by their mothers using continuous skin-to-skin contact 24 hours a day. They were exclusively breastfed or fed with breast milk, whenever possible, and discharged home early with a scheduled follow-up programme (1). This KMC model is now practised more frequently in lowincome settings, whereas in high-tech neonatal intensive care units (NICUs) intermittent KMC sessions of 1 or 2 h per day are more common. For the sake of simplicity, the term KMC will be used here to cover both continuous and intermittent care. Compared to conventional neonatal intensive care, with infants spending most of their time in an incubator, KMC yields several benefits (1,2). These include increased physiological stability, decreased pain response, stress reduction, better sleep state organisation and more normal neurobehavioural and psychomotor development. These effects are also noted in very and extremely preterm infants and term infants requiring intensive care. The method may contribute to fewer severe infections and reduce the infant’s hospital stay (3). Furthermore, KMC facilitates breastfeeding (1), especially for the most vulnerable infants (4). Other benefits include lower maternal depression scores and a
more developmentally oriented caregiving family environment during the first year, as fathers’ involvement in KMC also has a positive impact (2). Swedish mothers who practiced continuous KMC said that they liked this close contact with their infant, although some of them were dissatisfied with the support offered by the nursing staff (5). Swedish fathers who provided KMC from the infant’s birth felt that it helped them to establish their paternal role more quickly after birth, as they could provide the infant’s basic care and become more independent of the nurses (6). When an infant is admitted to a NICU, the new parents (rather than just the mother) need to bond with their new
Key notes
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 373–378
This study compared the intermittent model of Kangaroo Mother Care (KMC), which has been the norm in high-tech NICUs until recently, with continuous KMC. Staff who worked in a NICU that enabled continuous KMC were more positive and confident about the process, including its use in unstable infants. To successfully implement KMC, NICUs need to provide the facilities that parents need to stay with their children round-the-clock.
373
Kangaroo mother care in the NICU
Strand et al.
baby and interact with staff (7). As parent–infant bonding should be regarded one of the primary goals of neonatal care, KMC should be promoted as a means of humanising the care an infant receives, in addition to other benefits (8). The World Health Organisation has recommended KMC as a universal model of care in all types of settings, because the evidence shows that it benefits infants and families (9). As a result, starting continuous KMC immediately after birth, or as soon as possible after stabilisation, has also been recommended for infants in high-tech NICUs (2). However, as both positive and negative staff attitudes have been found to affect parents’ application of KMC, the method is an example of a clinical practice based on attitudes rather than scientific evidence (10). Although KMC is also safe for infants receiving mechanical ventilation (11), staff concerns about the early introduction of KMC and infant safety during the process are common (12). Staff have suggested that implementing the method could lead to unwelcome lower staffing levels and increased workloads (12). Furthermore, the signals conveyed by the physical and social environment in conventional high-tech NICUs do not encourage parents to stay with their infant (2). It can be assumed that providing family rooms and recliners or parent beds in NICUs may increase the parents’ presence and performance of KMC. This may, in turn, influence how staff perceive the method. The intermittent model of KMC has become common in affluent Western countries Therefore, the introduction of continuous KMC as the norm in a Swedish high-tech NICU (5,6,13) provided the impetus for this study, as research was lacking about staff attitudes to KMC in this type of setting, together with beliefs about the different modes of application.
AIM The aim of the study was to describe and compare staff attitudes towards KMC at NICUs that provided different opportunities for parents to stay with their infant and practice KMC. Two research questions were formulated. The first explored differences in staff attitudes to KMC between the NICUs, in relation to the benefits and drawbacks of KMC, infant criteria for the use of KMC, opinions about the parents’ performance of KMC and staff issues linked to KMC. The second focussed on the spontaneous comments about KMC made by the respondents in the two units. Our hypothesis was that staff who were positive about KMC would also be more positive in the unit that provided an environment that enabled the parents to be with their infants at all times.
MATERIAL AND METHODS Design A cross-sectional survey was carried out among all the clinical staff in two NICUs using a questionnaire (Likert scale) with additional space for free comments.
374
Setting and sample The study was performed in the NICUs at two Swedish University hospitals. It was carried out in Unit A 4 years after the NICU had been redesigned to enable at least one parent to stay with their child 24-hours-a-day throughout their whole hospital stay and provide 24/7 KMC if they wished. Guidelines for the introduction of continuous KMC, according to gestational age at birth, were introduced at the unit at the same time. In Sweden, the national insurance system makes it possible for parents to stay with their hospitalised child round-the-clock as both parents can share ‘temporary parental benefit’ until the infant is formally discharged from hospital. Unit A had 23 beds. These included 14 intensive care incubators or cribs in open bay nurseries, with an adult bed next to each of them, enabling one parent to stay 24 hours a day. Two adult beds were provided for parents with twins. The unit also included nine family rooms, where parents and siblings could stay day and night with the infant, from birth, or after the transition from the intensive-care nursery, until they were discharged. Relatives and other close friends were welcome to visit and could be designated by the parents as substitute KMC providers. The NICU provided a family kitchen and lounge and sibling play areas. Postnatal nursing care was provided by midwives in the postnatal ward, making it possible for mothers with normal deliveries to stay with their infants day and night from birth. Unit B was a conventional 17-bed NICU with five intensive-care beds and 12 intermediate-care beds. Parents had access to a recliner in their infant’s care space in both sections. This NICU had three family rooms, where parents could stay with their stable infant round-the-clock, at least for a couple of days before discharge. A family kitchen and lounge was also available. The parents were supported as much as possible if they wanted to provide KMC. In contrast with Unit A, the KMC protocol at Unit B did not include any guidelines for the introduction of continuous KMC. Approval to conduct this study was obtained from the medical directors of both study units. Data collection method The questionnaire design was based on a similar study (12) and the authors’ clinical experience. One nurse, physician and assistant nurse from each NICU reviewed the questionnaire to ensure its content and validity, and minor changes were made based on their suggestions. The questionnaire consisted of 22 statements about the benefits and drawbacks of KMC, infant criteria for the use of KMC, opinions about parents’ performance of KMC and staff issues linked to KMC. Participants were asked to indicate their agreement with each statement, using a Likert scale where 0 meant ‘disagree’ and 10 meant ‘strongly agree’. The questionnaire also included questions about the participants’ profession and experience of neonatal care, as well as questions requiring a ‘yes’ and ‘no’ answer on theoretical and practical education in KMC, written sources of knowledge about KMC and clarity of the NICU’s KMC guidelines.
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 373–378
Kangaroo mother care in the NICU
Strand et al.
Sample and data collection procedure All registered nurses (RN), physicians and assistant nurses working in the NICUs at the time of the data collection were invited to participate. A list of participants was compiled and questionnaires were numbered according to the list, making it possible to remind staff members who did not respond within the prescribed time. The list of participants was kept confidential and destroyed after the data collection had been completed. The questionnaires were distributed using individual mailboxes and lockers at the two NICUs. Participants who did not submit their questionnaires in 10 days were supplied with a new questionnaire and asked to submit it no later than 3 weeks later. Acceptable response rates were achieved after one reminder. Data analysis Data from the questionnaires were entered into the Statistical package for the social sciences (SPSS) version 20.0 (IBM corp., Armonk, NY, USA). The Mann–Whitney U-test was used to compare the independent samples. A p < 0.05 was considered significant. Responses to the open questions were categorised according to the four content areas in the questionnaire.
RESULTS Response rate and respondents’ profile We distributed a total of 165 questionnaires: 74% of the Unit A questionnaires were returned (85/115), together with 74% of the Unit B questionnaires (41/50). About half of the 85 respondents in Unit A were assistant nurses (42), followed by RNs (33) and 10 physicians. Most of the staff (69%) had worked in neonatal intensive care for 10 years or more. In Unit B, 25 respondents were RNs, 10 were assistant nurses and six were physicians. Three of four respondents (76%) had 10 years or more of experience of neonatal care. The majority of the participants in Unit A said that they had received theoretical education about KMC, compared to about half of the staff in Unit B. About three of four respondents in Unit A had participated in practical training, compared to about half of the respondents in Unit B. Nearly all of the respondents in Unit A agreed that the KMC guidelines were clear, whereas the proportion in Unit B was somewhat lower. The use of literature as a source of knowledge was less common in both units. About one of three participants in both NICUs had read about KMC on the internet. Staff responses to questionnaire statements Benefits and drawbacks of KMC Staff in both NICUs agreed about the positive effects of KMC on parent–infant bonding/attachment, parents’ selfconfidence and infants’ physiological status and general wellbeing (Table 1). However, staff in Unit A indicated lower agreement scores than staff in Unit B on overstating the benefits of KMC (a mean score of 1.3 versus 2.4) and that KMC increases the risk of hazards (1.7 versus 2.4).
Table 1 Benefits and drawbacks of KMC Statements Benefits KMC promotes parent–infant bonding/attachment KMC has positive effects on the infant’s physiological status KMC has positive effects on the infant’s general wellbeing KMC has positive effects on parents’ self-confidence Drawbacks Potential benefits of KMC have been overstated KMC leads to increased hazards for the infant
Unit A M (range)
Unit B M (range)
p
9.6 (5–10)
95 (7–10)
ns
9.3 (6–10)
9.1 (5–10)
ns
9.3 (5–10)
9.2 (6–10)
ns
9.3 (2–10)
9.0 (5–10)
ns
1.3 (0–9)
2.4 (0–8)
0.001
1.7 (0–9)
2.4 (0–6)
0.002
M = Mean; ns = Nonsignificant.
Several comments by respondents from Unit A addressed the risk of extubation and dislocation of umbilical catheters during infant transfer between the incubator and a parent, together with the risks for infants that may be too instable to tolerate KMC, especially extremely preterm infants. Correct infant positioning to ensure that their airways remained free and appropriate clothing during KMC were felt to be essential for infant safety. Infant criteria for use of KMC There were significant differences between the units regarding safety concerns (Table 2). Staff in Unit A were more positive about using KMC on infants receiving ventilator or continuous positive airways pressure treatment. Staff at both units expressed similar hesitation about using KMC in infants with an umbilical catheter and during the first week of life in infants born at a gestational age of below 28 weeks. Staff in both units were equally positive about introducing KMC in stable infants born at gestational ages of ≥28 weeks, One respondent in Unit B stated that the transfer of an intubated infant from the incubator to a parent required further deliberation before it became common practice, because of safety issues. Opinions on the parents’ performance of KMC Staff members in Unit A were more positive about offering all parents the opportunity to use KMC day and night, both in the family rooms and open bay nurseries. They were also convinced that parents would want to sleep with their infant skin-to-skin during the night (Table 3). Staff in both NICUs expressed mixed feelings about whether parents might feel forced to practice KMC by staff, with mean agreement scores of 4.9 in Unit A and 5.0 in Unit B. In Unit A, several comments addressed parents’ needs, especially when there were siblings, and highlighted the importance of easing parents’ stress by showing them
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 373–378
375
Kangaroo mother care in the NICU
Strand et al.
Table 2 Infant criteria for use of KMC Statements
Unit A M (range)
Unit B M (range)
p
5.0 (0–10) 3.0 (0–10) 0.9 (0–3)
0.000 ns 0.01
2.4 (0–10)
ns
9.2 (4–10)
ns
Unit A M (range)
Unit B M (range)
p
9.5 (5–10)
9.0 (4–10)
0.016
4.9 (0–10)
5.0 (1–10)
ns
8.4 (1–10)
6.4 (0–10)
0.000
8.7 (1–10)
6.1 (0–10)
0.000
6.3 (1–10)
4.2 (0–8)
0.000
KMC should be limited or avoided when the infant Is intubated 1.4 (0–8) Has an umbilical catheter 2.7 (0–8) Continuous positive airway pressure 0.5 (0–8) treatment is an obstacle to KMC KMC can be introduced during the 2.7 (0–10) first week of life when the infant born is at a postmenstrual age of
